That is from a recent article in The Journal of the American Medical Association, which reported a survey of elementary school-age children in New Orleans: 90 percent had witnessed violence; 70 percent had seen a weapon used; 40 percent had seen a corpse. An estimated 10 to 20 percent of Los Angeles homicides are witnessed by children. And a study at Boston City Hospital found 10 percent of the children treated in the pediatric primary care clinic have witnessed a shooting or stabbing before they are 6, half at home, half in the streets.
BCH has been serving Boston since 1864, when Sherman was burning Atlanta. Today there are war conditions, and war effects, in many urban neighborhoods. A recent study found similar post-traumatic stress disorders in children in war-torn Mozambique, Cambodia, the West Bank-and Chicago. The disorders include inability to concentrate, persistent sleep disturbance, flashbacks, sudden startling and hypervigilance, nihilistic and fatalistic orientation toward the future, leading to increased risk taking. To be a witness to violence is to be a victim of violence.
Small wonder that Boston has its share of what are known, in the grim argot of today’s cities, as “724 children”-children kept at home, indoors, seven days a week, 24 hours a day, because of the epidemic of violence. Some of the fortunate ones come into contact with the doctors and social workers at BCH, a hard-used hospital that gives new meaning to the phrase “family medicine.” Children are patients but families, such as they may be, are treated.
BCH’s youngest patients often ask why the adults in their lives-parents, teachers, police-can’t keep them safe. BCH physicians and social workers-a commingled group-regard as a treatable health problem the consequences of traumatically learning at an early age that the world is dangerous and unpredictable. A pervasive sense of danger, according to BCH doctors, causes people to make decisions that seem inexplicable to people more safely situated. For example, some women who are HIV-infected will still purposely get pregnant even though there is a 20 to 30 percent risk of having an infected child. Doctors say those odds do not seem so daunting when considered against the odds of being shot, raped, mugged … Besides, for the HIV-infected mother, childbirth is an affirmation of normality, of the fact that life goes on. Similarly, for a young inner-city male who sees death before 20 as common on the mean streets, a baby as an heir is an attractive idea.
A child who learns early to fear the world is apt to lose his or her natural proclivity for exploration of the world. A “724 child” may need to be taught how to participate in normal socializing play that other children learn naturally when growing up where civil peace prevails. Because we are apt to parent as we are parented, many unwed mothers or others from the culture of poverty need to be taught-and are movingly eager to learn-about talking, playing and reading with children. So BCH doctors have given children 9,000 books. Reading together can be therapy for families under the stress of crowding in apartments where children are kept on beds to prevent them from crawling on floors flecked with fragments of lead paint.
A BCH doctor notes that it is common to hear grandmothers living in poverty say of young children, “They’re smart when they’re little. They get dumb when they get older.” There is a sad wisdom behind such statements. The children of the poor are apt to be developmentally on a par with middle class children until, say, 2. Then apparent cognitive deterioration, relative to other children-actually, failure to attain potential-is apt to become noticeable. This is a result of various traumas and emotional and cognitive deprivations, in the withering of or failure to articulate parental expectations. This deterioration is neither necessary nor irreversible, but preventing it requires intense, unremitting one-on-one contact whereby a person with the coping skills necessary for flourishing in an urban setting imparts such skills to someone who lacks them. “We know how to do this,” says a BCH doctor. “It is fixable. It is just not a quick fix.”
It doubtless seems anomalous, and may be in some ways inefficient, for so many social services to be dispensed through the urban health care system. But an inner-city hospital often is, for its poorest patients, the point of entry into the system of social services. So BCH’s staff find themselves arranging with the employers of patients for time off for hospital visits; or dispensing basic nutritional counseling; or encouraging families to talk about everything from goals to heroes; or suggesting strategies of urban prudence.
This last, especially, can be urgent for health: an inner-city person who becomes a victim of violence has a 40 percent chance of becoming a victim again. This not only because of where he or she lives, but because of an inability to step away from the “bad vibes” of someone else’s ugly intent; or because of an inability to get angry-which is normal-without acting out the anger, action being the articulateness of the streets; or because a victim often looks like a victim. Social workers here say that of the appalling numbers of children carrying weapons to school most are not aggressive but frightened. (According to a 1990 survey by the Centers for Disease Control, 1 of every 5 high school students had carried a weapon and 1 in 20 had carried a gun in a 30-day period.) And many of the aggressive ones have been so desensitized by urban life that they feel alive only when enjoying a “rep” (reputation), something most quickly acquired by instilling fear.
So BCH’s staff does a lot that is not, strictly speaking, medicine. “But,” says one doctor, “it’s all health.” Says another, “This is not like trauma surgery, where you leap in, stop someone’s bleeding and are a hero in an instant.” Yes, but what BCH does is much more than medicine, and does much for the dignity of doctoring, and although it does not deal in instantaneous drama, it has its own heroism.
